Background. In high-income countries, preventative, long-term, and definitive care has seen mortality from cardiovascular disease (CVD) partially decline, while trends in low- to middle-income countries (LMICs) continue to exceed those of global averages. The burden of severe CVD-related events, especially crucially ST-segment myocardial infarction (STEMI), has risen disproportionally with socioeconomic pressures limiting preventative or definitive supports, particularly in rural or remote areas. Access to percutaneous coronary intervention (PCI) for STEMI in South Africa remains limited, inevitably expanding the therapeutic window to include pharmaco-invasive approaches with in-hospital thrombolysis (IHT) emerging as a widespread default STEMI intervention. Prehospital thrombolysis (PHT) may further bridge resource gaps and improve clinical outcomes due to time-sensitive benefits. Although not widely perceived as cost-prohibitive, cost concerns may however still act as a significant barrier to adoption of PHT. We analysed the cost-effectiveness of IHT in contrast to PHT. Methods. A cost-effectiveness analysis was conducted using a decision tree to compare PHT and IHT for the treatment of STEMI from a provider perspective. Cost estimates for analysis were obtained from publicly accessible data, including government, labour-earning reports, and industrial equipment pricing tiers. Deterministic and probabilistic sensitivity analyses were conducted to assess parameter uncertainty. The model estimated the incremental cost-effectiveness ratio (ICER), of implementing PHT relative to IHT by measuring outcomes using disability-adjusted life-years (DALYs). Results. Over a one-year period, PHT dominated IHT as a treatment strategy, demonstrating cost savings per DALY averted and life-years saved. Using PHT as an intervention resulted in cost savings of R190 500 per DALY averted, and R327 438 per life-year saved (LYS) in contrast to IHT. Savings in terms of cost and health outcomes were estimated at R23.78 million with incremental reduced deaths (n = 20), and fewer life-years lost (n = 149). Conclusion. Given the substantial burden of STEMI-related morbidity and mortality in South Africa, and the resource limitations faced by the public health sector, it is imperative to identify and implement cost-effective strategies to improve patient outcomes. In resource-constrained settings where timely access to PCI is limited, PHT represents a pragmatic and cost-effective strategy.
This short reflection draws upon political economy and historical and social perspectives to help make sense of the crises, forces and influences that have shaped global and planetary health and may do so in the foreseeable future. Our contribution reflects on the existing world order and its structures of political economy, with their ‘morbid symptoms’, or on ‘what is’. We then consider not only what planetary health ‘might be’, but also what it ‘ought to be’ for progressive, socially just and ecologically sustainable change to promote improvement in the health of people and our planet. To address the question of what might promote such transformations we introduce two concepts: the ‘symbiocene’ and the ‘post-modern princess’. These concepts may help us to theorise new forms of political agency orientated to ethically advancing that future scenario.
Tuberculosis (TB) remains the deadliest infectious disease globally, with gaps in case detection hindering its control. Active case-finding (ACF) comprises active screening of at-risk populations, including asymptomatic individuals, who constitute over half of TB prevalence in high-burden areas and who may contribute to community-based transmission. Common ACF models in community settings include door- to-door screening or mobile, vehicle-based screening using chest X-ray and/or molecular testing modalities. Other forms include healthcare facility-based screening and mass screening in congregate settings. The World Health Organization recommends ACF for communities with a TB prevalence of ≥0.5%, and its implementation is most effective in TB ‘hot spots’. ACF can also be focused on specific at-risk groups such as household contacts and people living with HIV. Despite resource and logistical challenges, community-based ACF trials have demonstrated significant reductions in TB prevalence with repeated rounds of screening. In practice, however, community-based ACF is rarely undertaken by TB programmes in endemic countries, owing to limited funding (‘willingness to pay’) and a lack of context-specific, evidence-based operational guidance on ACF implementation. Therefore, the real-world effect of ACF will likely depend on implementation intensity, the use of scalable and accurate screening and diagnostic tools, and engagement with communities and health systems.
From the Gluckman Commission’s call for a universal, equitable health system, through the racial exclusion of apartheid, to the reform agenda of the post-apartheid period, South Africa’s journey toward expanding universal health coverage (UHC) has been marked by historical inequities and bold reform visions. With current health sector reform initiatives challenged by polarising debates and legal contestation, this paper aims to compare and contrast reform options to encourage engagement and debate that advances UHC. An adapted UHC analytical framework is applied to four alternative health financing models that have either been implemented or considered in the post-apartheid period: the current public sector (National Health Service (NHS) model), the current private sector (voluntary health insurance), and two key alternatives, namely National Health Insurance (NHI) and Social Health Insurance (SHI). This analysis suggests that, while NHI offers the most comprehensive vision for UHC, its success depends on overcoming significant governance and fiscal constraints. SHI offers a more incremental and financially sustainable pathway by expanding formal sector coverage and enabling regulated risk pooling. However, a key finding is that no financing model, however well designed, will succeed without addressing underlying governance failures in the public health system. Drawing on lessons from the post-apartheid period, this paper argues for a phased hybrid approach that advances financing reforms alongside investment in governance capacity as the most feasible pathway to enable progress toward UHC.
Tuberculosis is the most common cause of hospitalisation and death globally among people with HIV (PWH), even in the antiretroviral therapy era. Diagnosis of tuberculosis is challenging in PWH as bacillary load is lower in sputum and a high proportion have extrapulmonary or disseminated tuberculosis. The clinical features of tuberculosis in PWH are nonspecific and there is a wide differential diagnosis of other opportunistic infections. Tuberculosis progresses rapidly in people with advanced HIV disease, necessitating rapid diagnosis. In this narrative review, key changes are described in the diagnosis of HIV-associated tuberculosis in adults from 1990 until the present. Smear microscopy was the only rapid diagnostic test for tuberculosis until 2011, but its sensitivity is lower in PWH. Algorithms for diagnosing smear-negative tuberculosis had poor diagnostic accuracy, resulting in both underdiagnosis, which increased tuberculosis deaths, and overdiagnosis, leading to missed or delayed diagnosis of the opportunistic infections causing the symptoms. The evidence base for screening for HIV-associated tuberculosis is strong among ambulatory PWH, but screening algorithms have lower sensitivity in people on antiretroviral therapy. The development of novel rapid diagnostic tests (nucleic acid amplification tests and urine lipoarabinomannan lateral flow assay) for tuberculosis and the advent of antiretroviral therapy have dramatically changed the landscape of diagnosing HIV- associated tuberculosis, resulting in reductions in both tuberculosis incidence and deaths. Diagnostic challenges persist as none of the currently available rapid diagnostic tests have sensitivities that are ideal, and only one test (urine lipoarabinomannan detection) is both affordable and simple to perform at the point of care. Therefore, there is still a need for the development of novel, accurate and affordable point-of-care tests to improve the rapid diagnosis of HIV-associated tuberculosis.
Advances in data science and medical artificial intelligence (AI) raise complex philosophical and ethical quandaries about what it means to know a person or a community through data and what kinds of people and societies we are becoming in this era of predictive data science. Drawing on four lightly fictional but reality-informed case studies in mental health, radiology, genomics and environmental public health, we reflect on how AI technologies, largely built on Western biomedical traditions, may conflict with relational, spiritual and Indigenous understandings of health and wellbeing. This may manifest as epistemic friction, algorithmic fatalism and diminished trust in patient-clinician relationships. Besides familiar concerns regarding bias and transparency, this paper advances the discourse on the ethics of medical AI and data science in healthcare by shifting the analysis from epistemology (how AI systems know, classify and predict) to ontology (the study of the nature of being, as reconfigured by data and AI). We argue that AI systems may inflict significant ontological harm by reconfiguring identity, moral agency and imagined futures and advocate for a renewed medical humanism driven by inter- philosophies dialogue, cross-cultural ethics and ecocentric approaches to care. From Bamenda, Cameroon, to Mthatha, South Africa and Toronto, Canada, the future of medical AI must be defined by the moral and philosophical traditions that people already live by. African, Indigenous, Islamic, Buddhist, Confucian and marginalised Western worldviews should not be treated as peripheral critiques, but as constitutive resources for building inclusive, human-centred health technologies. We conclude that bioethics should be recognised as a core infrastructure in global health, on equal footing with data science, medicine, biomedical research and health innovation.
The history of research in low- and middle-income countries is rife with practices that have extracted the time, energy, data, biological samples and, in many cases, the health and lives of those who participated, often justified by beliefs about their racial, cultural and civilisational inferiority. As global health research expanded in the late 20th century, this history raised substantial ethical concerns, including exploitation, double standards and the broader social, economic and political contexts in which international research occurs. Although research has contributed to reductions in mortality, morbidity and poverty, its benefits continue to accrue disproportionately to the wealthiest countries, even as access to the fruits of science has been recognised as a human right. In 1999, Prof. Solomon Benatar challenged the Global Forum for Bioethics in Research to confront research as an ‘extractive enterprise’ and to acknowledge the need for ‘a paradigm shift in thinking and action’, grounded in interdependence, duties, social justice and the promotion of human flourishing. The prevailing global paradigm, shaped largely by the US Common Rule regulations, emphasises institutional accountability, standardised procedures and a protectionist focus on individual research participants through regulatory compliance. Despite its influence, it remains unclear whether this model has advanced Prof. Benatar’s vision of a research enterprise that fosters inclusiveness and promotes the broader societal value of research. We outline possible shifts toward a more proactive, creative, inclusive, context-sensitive and innovative model that embraces empirical testing and global learning, with an emphasis on creating social value. These shifts reflect Prof. Benatar’s lifelong commitment to moral imagination, his call to reject extractive practices and his vision of a global research enterprise that enhances human flourishing, especially for the world’s most disadvantaged populations.
Background. An adrenal incidentaloma (AI) is a clinically unapparent adrenal mass >1 cm detected during imaging performed for reasons other than adrenal disease. The approach to AI is discussed extensively in international literature, but not specifically in resource-limited settings such as South Africa (SA). Objective. To describe the clinical, biochemical and radiological spectrum of AIs at Tygerberg Hospital (TBH), Cape Town, SA. Methods. This study was a retrospective descriptive review of all patients diagnosed with AI at TBH during the study period (1 January 2009 - 31 December 2023). Results. Two hundred and ninety-five (295) patient records were screened for inclusion using the radiology and admission records. Those excluded were duplicate entries (n=50), patients not meeting criteria for AI (n=47) and diagnosis of AI with no further investigation (n=113), leaving 85 patients included. A computed tomography scan was the most frequently utilised imaging modality (n=54; 64%). Indications were abdominal pain (n=27; 32%), other gastrointestinal complaints (n=10; 12%), abdominal mass (n=7; 8%), trauma (n=3; 4%) or other (n=38; 45%). Non-functional tumours comprised 87% (n=74). Functional tumours included pheochromocytoma (PCC) (n=5; 45%), mild autonomous cortisol secretion (MACS) (n=3; 27%), primary hypercortisolaemia (n=2; 18%) and androgen-producing tumours (n=1; 9%). Fourteen patients (16%) had surgery. Conclusion. Our study demonstrated that PCC and cortisol-producing adenomas were the most common functional tumours. This is in contrast to most international studies, which show MACS as the most common functional AI. This likely reflects regional screening bias and underutilisation of dexamethasone suppression testing, rather than the true disease prevalence of PCC in the Western Cape Province. A large proportion of patients with a diagnosis of AI did not undergo any further investigation. Awareness among clinicians and collaboration with radiologists for early identification and referral of AI cases is imperative.
BACKGROUND:Obesity, a health condition characterised by abnormal accumulation of body fat, is a major public health problem, with the number of affected individuals forecasted to rise sharply worldwide. Local epidemiological data are needed to understand the epidemic's specific characteristics and to implement effective evidence-based prevention strategies. OBJECTIVE:To provide insight into the South African (SA) obesity epidemic by analysing trends in the prevalence of general and abdominal obesity between 1998 and 2017. METHODS:Harmonised data on 134 029 adults (aged ≥18 years) from nine population surveys were analysed. For each survey dataset, the population distribution of body mass index (BMI), waist circumference (WC) and waist-to-height ratio (WHtR) was estimated, along with the prevalence of obesity and abdominal obesity according to standard epidemiological definitions. Metaregression models were fitted to estimate and compare the average rates of change of the multiple obesity indicators during the study period, for the whole population and by sex, population group, province of residence and geographical type (urban v. rural). RESULTS:Among women, the distribution of BMI, WC and WHtR showed a significant rightward shift between 1998 and 2017, with increases in median values of 1.38 (95% confidence interval (CI) 0.91 - 1.84) kg/m2/decade for BMI, 4.04 (1.27 - 6.82) cm/decade for WC and 0.03 (0.01 - 0.04) units/decade for WHtR. The prevalence of obesity rose sharply, from 29.5% (28.1 - 30.8%) in 1998 to 42.7% (41.0 - 44.4%) in 2017. The prevalence of WC-defined and WHtR-defined abdominal obesity increased from 60.0% (58.6 - 61.3%) to 77.2% (76.0 - 78.4%), and from 62.8% (61.4 - 64.2%) to 78.7% (77.4 - 80.0%), respectively. Among men, changes in the distribution were modest and median trends not statistically significant, at 0.1 (-0.27 - 0.47) kg/m2/decade for BMI, 1.19 (-0.48 - 2.87) cm/decade for WC and 0.01 (-0.01 - 0.02) units/decade for WHtR. Obesity prevalence rose from 10.1% (8.9 - 11.3%) in 1998 to 12.1% (10.7 - 13.4%) in 2017, WC-defined abdominal obesity from 21.6% (19.8 - 23.4%) to 26.4% (24.3 - 28.4%) and WHtR-defined abdominal obesity from 39.7% (37.8 - 41.7%) to 42.8% (40.6% - 45.0%). The prevalence of both general and abdominal obesity also differed across geographical type, province and population group, with a disproportionately rapid increase among groups and areas that initially exhibited lower prevalence. CONCLUSION:Between 1998 and 2017, the prevalence of both general and abdominal obesity in the SA adult population rose substantially. Evidence-based prevention efforts and policy strategies are urgently needed to curb the growing burden, especially among women.
Background. Despite the World Health Organization’s current focus on eliminating congenital syphilis (CS) as part of its triple elimination strategy, the incidence of CS in South Africa (SA) is increasing. This highly preventable disease causes high morbidity and mortality. Recent local data on the clinical presentation of CS and modifiable factors associated with vertical transmission are scarce. Objectives. To describe the maternal and neonatal characteristics of symptomatic and asymptomatic neonates admitted with CS, and to identify the modifiable factors leading to CS infection. Methods. We conducted a retrospective review of all CS cases diagnosed in live-born infants managed at General Justice Gizenga Mpanza Regional Hospital in KwaZulu-Natal Province, SA, between 1 December 2019 and 31 December 2020, describing clinical presentation and modifiable factors that contributed to the occurrence of CS. Outcomes were compared between symptomatic and asymptomatic infants, and clinical features were compared between surviving and non-surviving infants. Results. We recorded 54 cases of CS out of 7 535 live-born infants (0.7%), including two sets of twins. Mothers of infants with CS were more likely to be living with HIV (52% (n=27) v. 38% of all mothers delivering live-born infants at our facility (p=0.032)), and less likely to have attended antenatal care (ANC): 19% (n=10) did not attend ANC, v. 2% overall (p=0.000). Neonatal death occurred in 7 (13%) infants with CS. Forty (74%) of the infants were symptomatic, with hepatosplenomegaly being the most common finding (68% of infants with CS). In total, 78 modifiable factors contributing to CS were identified, and grouped into maternal factors and factors related to timing of diagnosis, the healthcare system, testing and hospital or clinic visits. For 18 mothers (33% of modifiable factors), the result of the syphilis test conducted during pregnancy was not traced, or no treatment was commenced; 14 (27%) seroconverted during pregnancy after an initial negative booking test. Conclusion. Our study confirms high morbidity and mortality associated with CS. We recommend the use of point-of-care rapid diagnostic tests (mono syphilis or dual HIV/syphilis) at regular intervals throughout pregnancy. Elimination of CS is challenging, with a high percentage of mothers of neonates with CS not attending ANC.
BACKGROUND:Very young adolescents (VYAs), aged 10 - 14 years, represent a critical yet frequently neglected demographic in the field of sexual and reproductive health and rights (SRHR) research and programming. This developmental stage is characterised by rapid biological, cognitive, social and emotional changes that shape future sexual and reproductive trajectories. Despite their importance, the SRHR needs of VYAs remain under-represented in policy, research and service provision, particularly in low- and middle-income countries. OBJECTIVES:To synthesise existing evidence on the SRHR needs of VYAs, examine barriers and facilitators to service access, and identify strategies to strengthen age-appropriate SRHR interventions. METHODS:A narrative review of English-language peer-reviewed literature, grey literature and global policy documents published between 2000 and 2024 was conducted using PubMed, Scopus and Google Scholar. Twenty-three relevant sources were included and synthesised thematically. RESULTS:VYAs experience intersecting vulnerabilities related to early pubertal onset, restrictive gender norms, limited access to accurate SRHR information, and health systems that are primarily oriented towards older adolescents and adults. Barriers to SRHR information and services were reported in approximately half of the reviewed sources. Evidence indicates that early, context-specific interventions - particularly comprehensive sexuality education, parental engagement and adolescent-responsive health services - can improve SRHR knowledge and protective behaviours. CONCLUSION:Addressing the SRHR needs of VYAs is essential for advancing public health equity and broader development goals. Integrating tailored, rights-based approaches across health, education and policy frameworks can support healthier transitions through early adolescence.
Background. Complicated urinary tract infections (cUTIs) are a growing burden in urological patients, particularly those with prior catheterisation or surgical procedures. Appropriate empirical antimicrobial therapy is an essential component in the management of these patients; therefore, treatment guidelines need to be reviewed periodically. Objectives. To evaluate the microbiological causes and antimicrobial resistance (AMR) patterns of cUTIs in a specialised urology department in KwaZulu-Natal Province, South Africa. Method. A retrospective study was conducted on all positive urine cultures of patients attending a urology clinic and ward from 1 January 2021 to 31 December 2023. Samples were processed according to standard operating procedures. Results. A total of 820 specimens were analysed in this study. Escherichia coli was the most common causative agent of cUTIs, accounting for 47% of all isolates, followed by Klebsiella spp. (15%). Enterococcus spp. was the most prevalent Gram-positive uropathogen. Notably, high resistance patterns were observed, with ciprofloxacin resistance rates of 79.4% in E. coli and 50.8% in Klebsiella spp. Extended-spectrum beta-lactamase-producing bacteria were detected in 43.3% of E. coli and 40.2% of Klebsiella spp. isolates, while carbapenem resistance was detected in 15.3% of Klebsiella spp. Conclusion. Our study shows the importance of antibiotic surveillance to guide empirical antimicrobial therapy based on local microbiological data. Owing to the increase in resistance of common uropathogens to commonly used antimicrobials, we advocate revised guidelines for the empirical treatment of cUTIs.
